UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT
PLANNED PARENTHOOD SOUTH ATLANTIC; JULIE EDWARDS, on her behalf and on behalf of all others similarly situated,
Plaintiffs – Appellees,
JOSHUA BAKER, in his official capacity as Director, South Carolina Department of Health and Human Services,
Defendant – Appellant.
ACCESS REPRODUCTIVE CARE-SOUTHEAST; AMERICAN ACADEMY OF PEDIATRICS; AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS; AMERICAN COLLEGE OF PHYSICIANS; AMERICAN MEDICAL ASSOCIATION; CENTER FOR REPRODUCTIVE RIGHTS; IPAS; IN OUR OWN VOICE: NATIONAL BLACK WOMEN’S REPRODUCTIVE JUSTICE AGENDA; NATIONAL ASIAN PACIFIC AMERICAN WOMEN’S FORUM; NATIONAL HEALTH LAW PROGRAM; NATIONAL LATINA INSTITUTE FOR REPRODUCTIVE HEALTH; SEXUALITY INFORMATION AND EDUCATION COUNCIL OF THE UNITED STATES; SOCIETY FOR ADOLESCENT HEALTH AND MEDICINE; SOCIETY FOR MATERNAL FETAL MEDICINE; WOMEN’S RIGHTS AND EMPOWERMENT NETWORK,
Amici Supporting Appellee.
Appeal from the United States District Court for the District of South Carolina, at Columbia. Mary G. Lewis, District Judge. (3:18-cv-02078-MGL)
Argued: September 20, 2019 Decided: October 29, 2019
Before WILKINSON, WYNN, and RICHARDSON, Circuit Judges.
Affirmed by published opinion. Judge Wilkinson wrote the opinion, in which Judge Wynn and Judge Richardson joined. Judge Richardson wrote a concurring opinion.
ARGUED: Kelly McPherson Jolley, JOLLEY LAW GROUP, LLC, Columbia, South Carolina, for Appellant. Alice Joanna Clapman, PLANNED PARENTHOOD FEDERATION OF AMERICA, Washington, D.C., for Appellees. ON BRIEF: Ariail B. Kirk, JOLLEY LAW GROUP, LLC, Columbia, South Carolina, for Appellant. M. Malissa Burnette, Kathleen McDaniel, BURNETTE, SHUTT & MCDANIEL, PA, Columbia, South Carolina, for Appellees. Jane Liu, Mariah Lindsay, NATIONAL ASIAN PACIFIC AMERICAN WOMEN’S FORUM, Washington, D.C.; Julie Rikelman, Pilar Herrero, Amy Myrick, Carolina Van Der Mensbrugghe, CENTER FOR REPRODUCTIVE RIGHTS, New York , New York, for Amici Access Reproductive Care-Southeast, Center for Reproductive Rights, In Our Own Voice: National Black Women’s Reproductive Justice Agenda, National Asian Pacific American Women’s Forum, National Latina Institute for Reproductive Health, and Women’s Rights and Empowerment Network. Janice M. Mac Avoy, Andrew B. Cashmore, Alexandra Verdi, FRIED, FRANK, HARRIS, SHRIVER & JACOBSON LLP, New York, New York, for Amici American College of Obstetricians and Gynecologists, American Medical Association, Society for Maternal Fetal Medicine, American Academy of Pediatrics, American College of Physicians, and Society for Adolescent Health and Medicine. Martha Jane Perkins, Sarah Jane Somers, NATIONAL HEALTH LAW PROGRAM, Carrboro, North Carolina, for Amici National Health Law Program, IPAS, and Sexuality Information and Education Council of the United States.
WILKINSON, Circuit Judge:
This case raises a question of statutory construction. We ask whether, and on what
basis, the Medicaid Act’s free-choice-of-provider provision affords a private right of action
to challenge a state’s exclusion of a healthcare provider from its Medicaid roster. The
district court here issued a preliminary injunction in favor of the individual plaintiff, a
Medicaid recipient, in her suit challenging South Carolina’s decision to terminate Planned
Parenthood South Atlantic’s (PPSAT) provider agreement because it offers abortion
services. The plaintiff was likely to succeed on the merits of this claim, the district court
held, for two interrelated reasons: first, the Medicaid Act’s free-choice-of-provider
provision, 42 U.S.C. § 1396a(a)(23)(A), confers on “any individual” a private right to sue
that may be enforced under 42 U.S.C. § 1983; and second, South Carolina denied plaintiff
the right to select the willing, qualified family-planning provider of her choice.
We now affirm. Based on the Supreme Court’s precedents, Congress’s intent to
create an individual right enforceable under § 1983 in the free-choice-of-provider provision
is unambiguous. In addition, a plain-language reading of the provision’s mandate—that
states “must” furnish Medicaid recipients the right to choose among providers “qualified
to perform the service or services required”—bars states from excluding providers for
reasons unrelated to professional competency. See 42 U.S.C. § 1396a(a)(23)(A), (p)(1).
Finding the remaining preliminary injunction factors satisfied, we shall uphold the trial
Medicaid is the nation’s public health insurance program for those of limited means.
The original beneficiaries of this program were low-income children and their parents, the
indigent elderly, the blind, and the disabled. Schweiker v. Gray Panthers, 453 U.S. 34 , 37
(1981). Since 1965, Congress has periodically expanded the program, adding, for instance,
pregnant women with family incomes up to 133% of the federal poverty level as a distinct
beneficiary class. See 42 U.S.C. § 1396a(a)(10)(A)(i), (l); Medicare Catastrophic Coverage
Act of 1988, Pub. L. No. 100-360, § 302, 102 Stat. 683, 750; Omnibus Budget
Reconciliation Act of 1989, Pub. L. No. 101-239, § 6401, 103 Stat. 2106, 2258.
A joint federal-state effort ensures that the healthcare needs of these beneficiaries
are met. In broad strokes, the Medicaid Act “offers the States a bargain: Congress provides
federal funds in exchange for the States’ agreement to spend them in accordance with
congressionally imposed conditions.” Armstrong v. Exceptional Child Ctr., 135 S. Ct.
1378 , 1382 (2015). The Act, to that end, charges the federal government with crafting
baseline eligibility requirements for recipients and providers, determining covered medical
services, and establishing reimbursement standards to the states. See 42 U.S.C. § 1396 et
seq.; NFIB v. Sebelius, 567 U.S. 519 , 541-42 (2012). Cooperating states then implement
the program, agreeing to abide by federal conditions in return for federal matching funds
that are used for expenses such as provider reimbursements. See Armstrong, 135 S. Ct. at
1382. Such funds are substantial; federal coffers finance anywhere from fifty to eighty-
three percent of state expenses, 42 U.S.C. § 1396d(b), an aggregate figure that accounts for
over ten percent of most states’ total revenue, NFIB, 567 U.S. at 542.
Congress designed the Medicaid program to ensure that states dispense federal
funds in compliance with federal rules. At the outset, states must propose and submit
Medicaid plans for the approval of the Centers for Medicare and Medicaid Services.
Douglas v. Indep. Living Ctr. of S. Cal., Inc., 565 U.S. 606 , 610 (2012). State departures
from federal requirements provide grounds for the Secretary of Health and Human Services
(HHS) to withhold Medicaid funding, either in whole or in part. See 42 U.S.C. § 1396c; 42
C.F.R. § 430.12(c). If federal requirements are met, however, states have “substantial
discretion to choose the proper mix of amount, scope, and duration limitations on coverage,
as long as care and services are provided in ‘the best interests of the recipients.’” Alexander
v. Choate, 469 U.S. 287 , 303 (1985) (quoting 42 U.S.C. § 1396a(a)(19)).
At issue here is the Medicaid Act’s free-choice-of-provider provision, 42 U.S.C.
§ 1396a(a)(23), which states:
A State plan for medical assistance must— provide that any individual eligible for medical assistance . . . may obtain such assistance from any institution, agency, community pharmacy, or person, qualified to perform the service or services required . . . who undertakes to provide him such services . . . .
42 U.S.C. § 1396a(a)(23)(A). That provision guarantees patients access to qualified and
willing providers. A state plan must generally allow Medicaid recipients to obtain care
from any provider who is “qualified to perform the service or services required” and “who
undertakes to provide . . . such services.”
In its mechanics, the free-choice-of-provider provision comports with the Medicaid
Act’s dual emphasis on federal standard-setting and state flexibility. While Medicaid
beneficiaries may generally seek medical services from willing providers of their choice,
states retain discretionary authority to determine whether entities are medically “qualified
to perform the service or services required.” States may also exclude providers from their
plans “for any reason for which the [federal] Secretary of [Health and Human Services]
could exclude the individual or entity,” 42 U.S.C. § 1396a(p)(1), or on certain state-law
grounds, see 42 C.F.R. § 431.51(c)(2).
This dispute arose following South Carolina’s termination of two Planned
Parenthood centers as Medicaid providers. PPSAT operates two healthcare centers in South
Carolina, one in Charleston and the other in Columbia. These centers provide a range of
family planning and preventative care services, including physical exams, cancer
screenings, contraceptive counseling, and pregnancy testing. For four decades, PPSAT has
been a South Carolina Medicaid provider that receives reimbursements for care provided
to Medicaid beneficiaries. In recent years, PPSAT’s South Carolina centers have treated
hundreds of patients insured through Medicaid annually.
Among those patients is the individual plaintiff in this case, who suffers from
diabetes and its resulting complications. J.A. 75-78. Because doctors have advised that
these complications would make it quite dangerous for her to carry a pregnancy to term,
the plaintiff considers it imperative that she have access to safe, effective birth control.
After the plaintiff had difficulty finding a doctor who accepted Medicaid patients and was
willing to provide her preferred form of birth control, she turned to PPSAT’s Columbia
center. At her PPSAT appointment, the doctors inserted an intrauterine device to prevent
pregnancy and informed her that her blood pressure was elevated. As a result, she sought
follow-up care from her endocrinologist to control her blood pressure. Because the plaintiff
was impressed with the care she received at PPSAT, she planned to switch her
gynecological and reproductive health care there.
In July 2018, South Carolina’s Department of Health and Human Services
(SCDHHS) terminated PPSAT’s Medicaid provider agreement. SCDHHS did not contend
that PPSAT was providing subpar service to its Medicaid patients, or to any other patients.
Instead, PPSAT was terminated solely because it performed abortions outside of the
Medicaid program. 1
According to SCDHHS, PPSAT’s termination was part of a plan by Governor Henry
McMaster designed to prevent the state from indirectly subsidizing abortion services. In
1995, the South Carolina legislature passed a law preventing state funds appropriated for
family planning services from being used to fund abortions. S.C. Code Ann. § 43-5-1185
(1995). After taking office in 2017, Governor McMaster issued two executive orders
designed to further this objective. The first, Executive Order 2017-15, directed state
agencies “to take any and all necessary actions . . . to the extent permitted by law, to cease
providing State or local funds . . . to any physician or professional medical practice
1 South Carolina does not provide Medicaid reimbursements for abortion services except in cases where it is required to do so by federal law. Such cases involve rape, incest, or the need to protect the mother’s life. See Consolidated Appropriations Act, 2018, Pub. L. No. 115-141, div. H, tit. V, §§ 506-507, 132 Stat. 348, 763-64 (Hyde Amendment).
affiliated with an abortion clinic . . . .” J.A. 56-58. The second, Executive Order 2018-21,
directed SCDHHS to “deem abortion clinics . . . and any affiliated physicians or
professional medical practices . . . that are enrolled in the Medicaid program as unqualified
to provide family planning services and, therefore, to immediately terminate them . . . .”
J.A. 70-71. SCDHHS responded quickly. On the day the second order was issued,
SCDHHS Officer of Health Programs Amanda Williams notified PPSAT by letter that
“[t]he Governor’s actions result in Planned Parenthood no longer being qualified to provide
services to Medicaid beneficiaries” and that PPSAT’s enrollment agreement with South
Carolina was terminated effective immediately. J.A. 73. As a result, PPSAT’s two South
Carolina centers began to turn away Medicaid patients. J.A. 13-14.
On July 27, 2018, PPSAT and the individual plaintiff (collectively, “plaintiffs”)
filed suit in federal district court in South Carolina against Joshua Baker, in his official
capacity as Director of SCDHHS. The individual plaintiff brought suit on her own behalf
and that of a purported class of South Carolina Medicaid beneficiaries who received, or
would like to receive, healthcare services at PPSAT. Plaintiffs brought this action under 42
U.S.C. § 1983, seeking injunctive and declaratory relief on the grounds that SCDHHS
violated their rights under the Medicaid Act and the Fourteenth Amendment. On July 30,
plaintiffs filed for preliminary injunctive relief solely on the basis of their Medicaid Act
claims. The district court held hearings on plaintiffs’ motion on August 23. In their
complaint and at the hearing, plaintiffs argued that the Medicaid Act’s free-choice-of-
provider provision confers on recipients a private right, enforceable under 42 U.S.C. 8
§ 1983, to use the qualified and willing provider of their choice, and that South Carolina
violated this right when it terminated PPSAT for reasons unrelated to its professional
competence to provide medical services.
The district court agreed with the plaintiffs and granted a preliminary injunction on
August 28, 2018. Because the district court held that injunctive relief was appropriate based
on the individual plaintiff’s Medicaid Act claim alone, it did not analyze PPSAT’s
Medicaid Act claim. First, it held that the individual plaintiff’s Medicaid Act claim was
likely to succeed on the merits. It agreed that the free-choice-of-provider provision confers
a private right, enforceable under 42 U.S.C. § 1983, on Medicaid-eligible patients,
guaranteeing their right to choose any willing provider “qualified to perform” the relevant
service. Critically, the court held that “qualified” should be given its ordinary meaning—
professionally competent. Relatedly, the district court rejected South Carolina’s contention
that § 1396a(p)(l) of the Medicaid Act gives a state plenary authority to exclude providers
from its program “for any reason whatsoever as long as the reason is bolstered by State
law.” Planned Parenthood S. Atl. v. Baker, 326 F. Supp. 3d 39 , 47-48 (D.S.C. 2018). To
the contrary, it held that the state’s authority to exclude providers is limited by the free-
Finally, the district court found that the other conditions necessary for a preliminary
injunction—irreparable harm, balancing of the equities, and the public interest—were
satisfied. In weighing the equities, the district court rejected South Carolina’s argument
that the state would be forced to subsidize abortions if it were enjoined from terminating
PPSAT’s provider agreement. Baker, 326 F. Supp. 3d at 49-50. First, because South
Carolina’s Medicaid program does not cover abortions except in the narrow circumstances
required by federal law, there was no direct subsidization of non-covered abortions. See id.
at 47. Second, because “PPSAT is reimbursed for Medicaid services on a fee-for-service
basis,” id. at 49, at rates that do not cover its costs, PPSAT’s participation in Medicaid did
not generate excess funds that could be used to indirectly subsidize abortions. See id. at 47,
49-50. Accordingly, the district court granted a preliminary injunction preventing South
Carolina from terminating PPSAT’s Medicaid enrollment agreement.
South Carolina timely appealed.
The free-choice-of-provider provision lies at the heart of this appeal. As noted
above, the provision states that:
A State plan for medical assistance must— provide that any individual eligible for medical assistance (including drugs) may obtain such assistance from any institution, agency, community pharmacy, or person, qualified to perform the service or services required (including an organization which provides such services, or arranges for their availability, on a prepayment basis), who undertakes to provide him such services . . . .
42 U.S.C. § 1396a(a)(23)(A) (emphases added).
It is difficult to imagine a clearer or more affirmative directive. The provision
applies to “any individual” eligible for Medicaid; grants these individuals the right to obtain
medical treatment from “any institution” willing and “qualified to perform the service or
services required”; and provides that state plans “must” comply. 2
2 Violation of a Medicaid recipient’s statutory right under the free-choice-of- provider provision visits “concrete” harm that is “real” and “tangible,” because the (Continued) 10
Congress could have made an exception for providers offering abortion services.
But it did not do so. Because we “presume that a legislature says in a statute what it means
and means in a statute what it says there,” Connecticut Nat’l Bank v. Germain, 503 U.S.
249 , 253-54 (1992), this court cannot write into a statute an exception that Congress did
not create. Accordingly, we take the free-choice-of-provider provision to mean that a
Medicaid recipient has the right to challenge a state’s exclusion of a provider from its
Medicaid plan on grounds unrelated to that provider’s willingness and professional
competency to furnish the required medical service.
It is important at the outset to place this case in proper context. As a matter of black
letter law, inferring a private right of action is a matter of statutory interpretation. If
Congress is silent or ambiguous, courts may not find a cause of action “no matter how
desirable that might be as a policy matter.” Alexander v. Sandoval, 532 U.S. 275 , 286-87
But it was not always this way, and a brief overview of this history is useful
background to the present lawsuit. We begin with J.I. Case Co. v. Borak, 377 U.S. 426
(1964), where the Supreme Court stated that federal courts were partners of Congress,
making it “the duty of the courts to be alert to provide such remedies as are necessary to
recipient can no longer receive care at his or her provider of choice. See Spokeo, Inc. v. Robins, 136 S. Ct. 1540 , 1548-49 (2016). This is the exact harm that Congress intended the provision to prevent. See id.
make effective the congressional purpose” expressed by a statute. Id. at 433. During the
Borak era, the “exercise of judicial power” was not “justified in terms of statutory
construction,” but rather as a means of crafting “substantive social policy.” Bivens v. Six
Unknown Named Agents of Fed. Bureau of Narcotics, 403 U.S. 388 , 402, 402 n.4 (1971)
(Harlan, J., concurring in judgment).
Some years later, Justice Powell derided Borak’s approach in an oft-quoted dissent.
Cannon v. Univ. of Chicago, 441 U.S. 677 , 742 (1979) (Powell, J., dissenting). In Powell’s
view, freely implying private rights of action posed two related constitutional problems.
First, to infer from silence the right to file suit in federal court interferes with Congress’s
Article III power to set “the jurisdiction of the lower federal courts.” Id. at 730. Second, an
expansive approach to implied private rights of action “cannot be squared with the doctrine
of the separation of powers.” Id. This is because a court’s “substitut[ion of] its own views
as to the desirability of private enforcement,” id. at 740, dispatches Congress’s Article I
“policymaking authority” to the Third Branch of government, id. at 743. “When Congress
chooses not to provide a private civil remedy, federal courts should not assume the
legislative role of creating such a remedy and thereby enlarge their jurisdiction.” Id. at 730-
31. Therefore, “[a]bsent the most compelling evidence of affirmative congressional intent,
a federal court should not infer a private cause of action.” Id. at 731.
Justice Powell’s dissent primed the Court for a doctrinal about-face. The Court
incrementally swore “off the habit of venturing beyond Congress’s intent,” Sandoval, 532
U.S. at 286-87 (tracing this doctrinal evolution), instead limiting its focus to the specific
statutory text at issue. In Sandoval, the Court summed up the result of this doctrinal
progression: “The judicial task is to interpret the statute Congress has passed to determine
whether it displays an intent to create not just a private right but also a private remedy.” Id.
But there was a loose end remaining—what to do with implied rights of action
brought under § 1983. Some litigants argued that § 1983 provided plaintiffs with a separate
cause of action if they fell “within the general zone of interest” of a federal statute. Gonzaga
Univ. v. Doe, 536 U.S. 273 , 282-83 (2002) (citing Blessing v. Freestone, 520 U.S. 329 ,
340-41 (1997)). The Court swiftly corrected this misunderstanding in Gonzaga, instructing
that § 1983 creates a cause of action to enforce a federal statute only when the underlying
statute itself unambiguously “confers an individual right” on the plaintiff. Id. at 284-85. If
so, the § 1983 remedy follows as a matter of course; litigants need not separately
demonstrate Congress’s intent to create a private remedy. Id.
With this background as guidance, we review the district court’s entry of a
preliminary injunction for “abuse of discretion, accepting the court’s findings of fact absent
clear error, but reviewing its conclusions of law de novo.” Child Evangelism Fellowship of
Md., Inc. v. Montgomery Cty. Pub. Sch., 373 F.3d 589 , 593 (4th Cir. 2004). To that end,
the individual plaintiff “must establish that [s]he is likely to succeed on the merits, that
[s]he is likely to suffer irreparable harm in the absence of preliminary relief, that the
balance of equities tips in h[er] favor, and that an injunction is in the public interest.” Winter
v. Nat. Res. Def. Council, Inc., 555 U.S. 7 , 20 (2008). We are mindful at once that a
preliminary injunction is an “extraordinary remedy,” id. at 22, but its issuance “is
committed to the sound discretion of the trial court,” Centro Tepeyac v. Montgomery Cty.,
722 F.3d 184 , 188 (4th Cir. 2013) (en banc) (quoting Quince Orchard Valley Citizens Ass’n
v. Hodel, 872 F.2d 75 , 78 (4th Cir. 1989)).
First we consider the threshold question whether the Medicaid Act’s free-choice-of-
provider provision creates a private right enforceable under § 1983. Section 1983 creates a
federal remedy against anyone who, under color of state law, deprives a person “of any
rights, privileges, or immunities secured by the Constitution and laws.” 42 U.S.C. § 1983.
Of course, it “does not provide an avenue for relief every time a state actor violates a federal
law.” City of Rancho Palos Verdes v. Abrams, 544 U.S. 113 , 119 (2005). Rather a plaintiff
seeking redress “must assert the violation of a federal right, not merely a violation of
federal law.” Blessing, 520 U.S. at 340.
Three factors guide us in determining whether a statute creates a private right
enforceable under § 1983. Id. at 340-41. “First, Congress must have intended that the
provision in question benefit the plaintiff.” Id. at 340. “Second, the plaintiff must
demonstrate that the right assertedly protected by the statute is not so ‘vague and
amorphous’ that its enforcement would strain judicial competence.” Id. at 340-41. “Third,
the statute must unambiguously impose a binding obligation on the States” by speaking “in
mandatory, rather than precatory, terms.” Id. at 341. If these three factors are satisfied,
there is “a rebuttable presumption that the right is enforceable under § 1983,” id., which
may be defeated by showing that Congress expressly or implicitly foreclosed a § 1983
remedy, City of Rancho Palos Verdes, 544 U.S. at 120.
Applying these principles, we agree with the district court—and five of our six sister
circuits to have addressed this issue—that the free-choice-of-provider provision confers a
private right, enforceable under § 1983, on Medicaid recipients. See Planned Parenthood
of Kan. & Mid-Mo. v. Andersen, 882 F.3d 1205 , 1224 (10th Cir. 2018); Planned
Parenthood of Gulf Coast, Inc. v. Gee, 862 F.3d 445 , 457 (5th Cir. 2017); Planned
Parenthood Ariz. Inc. v. Betlach, 727 F.3d 960 , 965-66 (9th Cir. 2013); Planned
Parenthood of Ind., Inc. v. Comm’r of Ind. State Dep’t of Health, 699 F.3d 962 , 968, 972-
74 (7th Cir. 2012); Harris v. Olszewski, 442 F.3d 456 , 461 (6th Cir. 2006). But see Does v.
Gillespie, 867 F.3d 1034 , 1037, 1041, 1046 (8th Cir. 2017).
Taking the first Blessing factor, the free-choice-of-provider provision
“unambiguously gives Medicaid-eligible patients an individual right” to their choice of
provider qualified to perform a medical service. Planned Parenthood of Ind., 699 F.3d at
974. The provision has an “unmistakable focus,” Gonzaga, 536 U.S. at 284, on its intended
class of beneficiaries: “any individual eligible for medical assistance” under the Medicaid
Act, 42 U.S.C. § 1396a(a)(23)(A). See Doe v. Kidd, 501 F.3d 348 , 356 (4th Cir. 2007)
(finding that 42 U.S.C. § 1396a(a)(8), which refers to “all individuals wishing to make
application for medical assistance,” confers an individual right).
Congress’s use of the phrase “any individual” is a prime example of the kind of
“rights-creating” language required to confer a personal right on a discrete class of
persons—here, Medicaid beneficiaries. See, e.g., Sandoval, 532 U.S. at 288 (providing an
example of rights-creating language: “No person . . . shall . . . be subjected to
discrimination . . . .”). Put differently, by adopting as its benchmark whether the “needs of
any particular person have been satisfied,” Gonzaga, 536 U.S. at 288, Congress left no
doubt that it intended to guarantee each Medicaid recipient’s free choice of provider.
As for the second Blessing factor, the free-choice-of-provider provision is not so
“vague and amorphous,” Blessing, 520 U.S. at 340-41, that its enforcement would strain
judicial competence. The provision protects the right of a Medicaid recipient to seek care
from his or her provider of choice, subject to two criteria: (1) the provider must be
“qualified to perform the service or services required,” and (2) the provider must
“undertake to provide [the recipient] such services.” 42 U.S.C. § 1396a(a)(23)(A). These
criteria are objective. The second is “a simple factual question no different from those
courts decide every day.” Betlach, 727 F.3d at 967. And the first, which “may require more
factual development or expert input,” still falls squarely “within the range of judicial
In an attempt to create ambiguity, South Carolina focuses on the word “qualified”
in isolation, Appellant’s Reply Brief at 9-10, ignoring the reality that the term is “tethered
to an objective benchmark: ‘qualified to perform the service or services required.’”
Betlach, 727 F.3d at 967-68 (quoting 42 U.S.C. § 1396a(a)(23)(A)). That omission makes
all the difference. Courts can “readily determine” whether a provider is qualified to perform
a service by “drawing on evidence such as descriptions of the service required; state
licensing requirements; the provider’s credentials, licenses, and experience; and expert
testimony regarding the appropriate credentials for providing the service.” Id. at 968. This
factual determination “is no different from the sorts of qualification or expertise
assessments that courts routinely make in various contexts.” Id. 3
Finally, the free-choice-of-provider provision “unambiguously impose[s] a binding
obligation on the States.” Blessing, 520 U.S. at 341. Under the provision, states “must
provide” a Medicaid recipient with his or her choice of provider qualified to perform the
service at issue. 42 U.S.C. § 1396a(a)(23)(A). Thus the provision is “couched in
mandatory, rather than precatory, terms.” Blessing, 520 U.S. at 341; see also Kidd, 501
F.3d at 356 (holding, as mandatory, a Medicaid provision requiring that state plans “must”
provide for reasonably prompt medical assistance).
Since the three Blessing factors are satisfied, the individual plaintiff benefits from a
rebuttable presumption that the free-choice-of-provider provision is enforceable under
§ 1983. Blessing, 520 U.S. at 341. That presumption has not been overcome. As an initial
matter, nowhere in the Medicaid Act did Congress declare an express intent to “specifically
foreclose a remedy under § 1983.” Id. (internal quotations omitted).
Nor can such an intent be implied: the Medicaid Act does not contain a
“comprehensive enforcement scheme . . . incompatible with individual enforcement under
§ 1983.” Id. Because South Carolina assumed that the free-choice-of-provider requirement
did not confer an individual right, it did not expressly press a rebuttal argument before this
3 A distinct note of caution is in order. To say that the term “qualified” is susceptible to federal judicial measurement for purposes of the second prong of Blessing is not the same thing as saying that states lack discretion in defining professional qualifications under 42 U.S.C. § 1396a(p)(1), or that they are not due deference in their termination decisions. See infra Section VI.B. In this case, PPSAT’s qualifications are simply not in dispute.
court. Even if it had, we conclude that the Medicaid Act’s enforcement scheme is not
sufficiently “comprehensive” to foreclose a private right of action enforceable under
§ 1983. Three alternative remedies are provided for in the Act: (1) the Secretary of HHS’s
authority to review state Medicaid plans for noncompliance and curtail or cut off Medicaid
funding as a matter of discretion, 42 U.S.C. §§ 1316(a), 1396c; 42 C.F.R. § 430.12; (2) a
state administrative process for providers to challenge termination decisions, 42 U.S.C.
§ 1396a(a)(4); 42 C.F.R. § 1002.213; and (3) a state administrative process for Medicaid
recipients to challenge a claim denial, 42 U.S.C. § 1396a(a)(3).
These remedies, taken together, are quite different from the “unusually elaborate
enforcement provisions” that the Supreme Court has taken as evidence that Congress
intended to preclude individual enforcement under § 1983. Middlesex Cty. Sewerage Auth.
v. Nat’l Sea Clammers Ass’n, 453 U.S. 1 , 13-14 (1981). The relevant pollution control
statute at issue in Middlesex County is illustrative. That statute authorized governmental
officials to respond to violations of the act with compliance orders and civil suits; permitted
the imposition of penalties up to $10,000 per day; and made criminal penalties available.
Id. at 13. Separately, the act also conferred on “any interested person” the right to seek
judicial review of relevant acts by federal officials, such as the issuance of an effluent
permit. Id. at 13-14. By prescribing the particular remedies available to public and private
actors, Congress demonstrated its intent to foreclose forms of relief otherwise available to
plaintiffs bringing § 1983 claims. See id. at 14-15.
Nothing comparable to this detailed enforcement scheme exists in the Medicaid Act.
To state the obvious, individuals are not ordinarily plaintiffs in provider suits, and an
individual’s administrative remedy to challenge, for example, a denial of Medicaid
coverage for a particular “service” does not also provide a forum for contesting the
disqualification of a preferred provider. This much is clear to South Carolina, so it seems
to latch onto the Secretary’s ability to cut Medicaid funds as itself indicative of a
comprehensive administrative enforcement scheme. See Appellant’s Opening Brief at 26-
27. But a remedy is not comprehensive solely because it is drastic, and to view a wholesale
cutoff of funding to the states as vindicating the interests of individual Medicaid
beneficiaries in their choice of provider would be illogical.
The illogic of this argument aside, the Supreme Court has already held that the
Medicaid Act’s administrative scheme is not sufficiently comprehensive to foreclose a
private right of action enforceable under § 1983. Wilder v. Virginia Hosp. Ass’n, 496 U.S.
498 , 521-22 (1990); see also Kidd, 501 F.3d at 356 (holding that the Medicaid Act neither
explicitly nor implicitly “forbid[s] recourse to § 1983”). The Court’s decision in Gonzaga
cut back on Wilder’s treatment of implied rights of action in the § 1983 context;
specifically, Gonzaga clarified that Congress must create an “unambiguously conferred
right” rather than merely confer a “benefit” on a plaintiff to establish a cause of action
enforceable under § 1983. Gonzaga, 536 U.S. at 282. But Wilder’s reasoning as to the
comprehensiveness of the Medicaid Act’s enforcement scheme has not been overturned.
See Andersen, 882 F.3d at 1229, 1229 n.16 (recognizing the same).
In sum, the Medicaid Act’s enforcement scheme is not sufficiently “comprehensive”
because, inter alia, it does not provide a private remedy—either judicial or administrative—
for patients seeking to vindicate their rights under the free-choice-of-provider provision. 4
See City of Rancho Palos Verdes, 544 U.S. at 121 (“[I]n all of the cases in which we have
held that § 1983 is available for violation of a federal statute, we have emphasized that the
statute at issue . . . did not provide a private judicial remedy (or, in most of the cases, even
a private administrative remedy) for the rights violated.”). The reason Congress did not
specify a method of private enforcement is plain: Section 1983 was to be the remedy for
patients seeking to enforce their rights under the free-choice-of-provider provision.
Permitting private enforcement of this type of suit, Congress realized, “in no way
interferes” with the Secretary of HHS’s authority to audit and sanction noncompliant state
Medicaid plans. Planned Parenthood of Ind., 699 F.3d at 975.
Thus, the Medicaid Act provides no comprehensive enforcement scheme sufficient
to overcome the presumption that the free-choice-of-provider provision is enforceable
under § 1983. Blessing, 520 U.S. at 341. The plain, direct language of that provision
unmistakably confers on a discrete class of individual Medicaid beneficiaries the right to
seek medical assistance from any qualified medical provider who is willing to provide the
required medical service. If that language does not suffice to confer a private right,
4 South Carolina’s contention that the individual plaintiff had a state administrative remedy she was required to exhaust before bringing a § 1983 suit is misguided. “[A]s a general rule, a plaintiff bringing a suit pursuant to 42 U.S.C. § 1983 does not have to exhaust state administrative remedies before filing suit in federal court.” Talbot v. Lucy Corr Nursing Home, 118 F.3d 215 , 218 (4th Cir. 1997) (citing Patsy v. Bd. of Regents of State of Fla., 457 U.S. 496 , 512 (1982)). At any rate, we agree with the district court that even if the individual plaintiff had a state administrative remedy available to her, it would, given the circumstances here, be futile. Baker, 326 F. Supp. 3d at 46-47.
enforceable under § 1983, upon the plaintiff here, it is difficult to see what language would
be adequate. To hold in South Carolina’s favor here would simply be to remove § 1983 as
a vehicle for private rights enforcement and essentially to require Congress to set forth a
cause of action enforceable purely on its own terms. We do not believe that the Court has
channeled the expression of congressional intent in such a fashion, nor do we believe that
we are free to do so. See Blessing, 520 U.S. at 340-41. Because South Carolina has not
rebutted the presumption that a private right of action exists, we join the Fifth, Sixth,
Seventh, Ninth, and Tenth Circuits in finding that the free-choice-of-provider provision
creates a private right enforceable under § 1983. See Andersen, 882 F.3d at 1224; Gee, 862
F.3d at 457; Betlach, 727 F.3d at 965-66; Planned Parenthood of Ind., 699 F.3d at 968,
972-74; Harris, 442 F.3d at 461. But see Gillespie, 867 F.3d at 1041, 1046.
We are mindful of two principal, and principled, objections to according the plaintiff
her requested relief. First, we should not freely infer private rights of action that are
enforceable under § 1983. Second, because Spending Clause legislation is in the nature of
a contract, we should not construe it so as to ambush states with terms that the states did
not foresee or bargain for. These are doctrines of importance and great force, but both
presuppose some level of textual ambiguity. Because that ambiguity is absent here, we
begin and end our search for Congress’s intent with the plain text of the free-choice-of-
First, courts are most definitely not at liberty to imply private rights of action willy-
nilly. Congress’s intent to make a private right enforceable under § 1983 must be
“unmistakably clear.” Gonzaga, 536 U.S. at 286 (internal citations omitted). This
requirement ensures that courts enforce private rights under § 1983 only when Congress
has so intended. Here, Congress unambiguously intended to create a private right—in favor
of “any individual” receiving Medicaid assistance—in the free-choice-of-provider
provision. Medicaid recipients, it is clear, are not merely within the provision’s “general
zone of interest.” See id. at 283.
We do not reach this conclusion lightly, but only after closely examining Congress’s
intent underlying the “specific statutory provision” at issue. Blessing, 520 U.S. at 342-43.
South Carolina reaches beyond the plain and narrow text of the free-choice-of-provider
provision—to eighty-two other provisions in the Medicaid Act—to conclude that the
provision is no more than a “plan requirement,” rather than an individual right. Appellant’s
Opening Brief at 23. However, Congress foreclosed any argument that an individual plan
requirement in the Medicaid Act cannot be enforceable through an implied private right of
action. 42 U.S.C. § 1320a–2 (A provision “is not to be deemed unenforceable because of
its inclusion in a section of [the Act] . . . specifying the required contents of a State plan.
This section is not intended to limit or expand the grounds for determining the availability
of private actions to enforce State plan requirements . . . .”). Quite apart from that clause,
however, ignoring Congress’s clearly expressed intent to create a private right of action
here is no less a usurpation of Congress’s “policymaking authority,” see Cannon, 441 U.S.
at 743 (Powell, J., dissenting), than reading a cause of action into a statute where Congress
did not create one, see Borak, 377 U.S. at 433.
Second, courts must be especially cautious in finding that a provision in Spending
Clause legislation, such as the Medicaid Act, creates a private right enforceable under
§ 1983. Spending Clause legislation, as noted, has been likened to a contract: “[I]n return
for federal funds, the States agree to comply with federally imposed conditions. The
legitimacy of Congress’ power to legislate under the spending power thus rests on whether
the State voluntarily and knowingly accepts the terms of the ‘contract.’” Pennhurst State
Sch. & Hosp. v. Halderman, 451 U.S. 1 , 17 (1981). Since a state cannot voluntarily and
knowingly accept conditions unknown to it, “if Congress intends to impose a condition on
the grant of federal moneys, it must do so unambiguously.” Id.
So much is true here. The terms of the Medicaid agreement are clear; in return for
substantial federal funds, states are required to comply with the unambiguous terms of the
free-choice-of-provider provision. And for the reasons described above, this obligation is
enforceable by recipients, the intended beneficiaries of the provision. When, as here, the
private cause of action is “unambiguously conferred” on a third party, see Armstrong, 135
S. Ct. at 1388 (plurality), courts cannot deprive the sovereign signatories to a “contract”
such as the Medicaid Act of the benefit of their bargain.
Nor may courts relieve them of the agreement’s consequences. Here, South Carolina
would like to avoid the obligations imposed by this fair bargain. In essence, the state argues
that some Supreme Court decisions might suggest a move away from inferring private
rights of action in Spending Clause legislation. See, e.g., Appellant’s Opening Brief at 29-
30 (“The [Gonzaga] Court noted that ‘[m]ore recent decisions have rejected attempts to
infer enforceable rights from Spending Clause statutes.’”) (quoting Gonzaga, 536 U.S. at
281). South Carolina may or may not be correct in its doctrinal forecast, but for now its
argument remains speculative and conjectural. As the Seventh Circuit noted:
[N]othing in Armstrong, Gonzaga, or any other case we have found supports the idea that plaintiffs are now flatly forbidden in section 1983 actions to rely on a statute passed pursuant to Congress’s Spending Clause powers. There would have been no need, had that been the Court’s intent, to send lower courts off on a search for “unambiguously conferred rights.” A simple “no” would have sufficed.
BT Bourbonnais Care, LLC v. Norwood, 866 F.3d 815 , 820-21 (7th Cir. 2017). We agree.
At bottom, the Court’s cases require us to find an “unambiguously conferred” right,
Armstrong, 135 S. Ct. at 1387-88 (plurality), which is exactly what we have done here. In
the end, the concerns identified above are not controlling in this case, because the free-
choice-of-provider provision unambiguously creates a private right in favor of the
Having decided that Congress unambiguously intended to create a private right of
action in the free-choice-of-provider provision, we turn now to consider the scope of the
right it confers on Medicaid recipients. A reasoned textual analysis in this case requires
only two steps. First, “[a]s always, we start with the specific statutory language in dispute.”
Murphy v. Smith, 138 S. Ct. 784 , 787 (2018). In the free-choice-of-provider provision,
“qualified to perform the service or services required” means what it says: professionally
fit to perform the medical services the patient requires. Second, we look to § 1396a(p)(1),
which describes a state’s authority to exclude providers from its Medicaid plan. In the end,
we find that the free-choice-of-provider provision in § 1396a(a)(23)(A) and the state’s
discretionary authority under § 1396a(p)(1) work in tandem to accomplish Congress’s
overall objectives in this cooperative federalism scheme.
First principles guide us in deciding what it means for a provider to be “qualified to
perform the service or services required” under the free-choice-of-provider provision.
“Unless otherwise defined, statutory terms are generally interpreted in accordance with
their ordinary meaning.” BP Am. Prod. Co. v. Burton, 549 U.S. 84 , 91 (2006). Because the
Medicaid Act does not define the term “qualified,” we consider its plain meaning—namely,
“having an officially recognized qualification to practice as a member of a particular
profession; fit, competent.” Oxford English Dictionary (3d ed. 2007); see also Black’s Law
Dictionary 1360 (9th ed. 2009) (defining “qualified” as “[p]ossessing the necessary
qualifications; capable or competent”).
Every circuit to have considered this issue is in accord with that straightforward
definition. See, e.g., Andersen, 882 F.3d at 1230; Gee, 862 F.3d at 459-60; Betlach, 727
F.3d at 967-68; Planned Parenthood of Ind., 699 F.3d at 978. But see Gillespie, 867 F.3d
at 1046 (declining to reach this question after concluding that the free-choice-of-provider
provision does not provide patients with a private right of action enforceable under § 1983).
South Carolina does not contest the fact that PPSAT is professionally qualified to
deliver the services that the individual plaintiff seeks. Nowhere in its submissions to this
court does the state seek to raise doubts that PPSAT satisfies the ordinary definition of
“qualified” as being professionally capable or competent. Instead, the state seeks to
persuade us that “qualified” means something other than what it says or that the structure
of the statute as a whole entrusts the word to the states to define its meaning.
The term, however, is in a federal statute and we are obliged to give it the meaning
that Congress intended, so long as that meaning is clear to its state partners in this
cooperative program. There is no question that the ordinary meaning of the term
“qualified” is the one Congress intended. Were there any doubt as to its intent, Congress
provided more specificity in the terms surrounding “qualified.” The free-choice-of-
provider provision guarantees Medicaid recipients the right to “obtain [medical] assistance
from any institution, agency . . . or person qualified to perform the service or services
required.” 42 U.S.C. § 1396a(a)(23)(A) (emphasis added). The plain import of this
language is to tie the word “qualified” to the performance of a service—and not just any
service, but a medical service. Tellingly, the statute does not differentiate among different
types of medical services, laying bare what can be the only reasonable interpretation of
“qualified” in this context: capable of “carry[ing] out a particular activity—‘perform[ing]
the [medical] service’ that a given Medicaid recipient requires.’” Betlach, 727 F.3d at 969.
It follows that the types of “qualifications” that are intended relate to a provider’s
competency to perform a particular medical service, and not to any conceivable state
interest as applied to the Medicaid program.
Reading “qualified to perform” in the free-choice-of-provider provision to mean
professionally competent accords with the way Congress ordinarily uses the phrase. See
Mount Lemmon Fire Dist. v. Guido, 139 S. Ct. 22 , 26 (2018) (finding it “instructive” that
a phrase “occurs dozens of times throughout the U.S. Code, typically carrying [its ordinary
meaning]”). Consider, for example, 8 U.S.C. § 1188(c)(3), which directs the Secretary of
Labor to find that “there are not sufficient workers in the United States who are able,
willing, and qualified to perform the labor or service needed” before admitting temporary
H-2A workers. This provision, like many others in the U.S. Code, specifies some service
or function as the object of the phrase “qualified to perform.” See, e.g., 49 U.S.C. § 5329(e)
(awarding states funding to carry out a federal public transportation safety program if,
among other things, members of the state agency “responsible for rail fixed guideway
public transportation safety oversight” are “qualified to perform such functions through
appropriate training”); 37 U.S.C. § 301b(b)(3) (defining “covered officers” as including
those “qualified to perform operational flying duty”). To read the phrase as denoting
anything other than fitness to perform the activity identified would be highly unusual.
In short, Congress’s handiwork here makes good sense. As a matter of ordinary
English, one’s preferred dry cleaner is not made unqualified to perform cleaning services
because he disfavors bicycles or because he did not vote in the last state election, even
though the state may prefer otherwise. Yet that is precisely the sort of result produced by
South Carolina’s reading of “qualified,” which would allow the state to exclude providers
based on any conceivable state interest. PPSAT, as South Carolina all but admits, is
perfectly competent to perform the family-planning services required by plaintiff and is
licensed to do so. The state nevertheless suggests that it may disqualify a competent
provider under state law so long as there is “good reason.” See Appellant’s Opening Brief
at 24. Today that reason is PPSAT’s provisioning of abortion services, but we cannot glean
any principled limit to the state’s exclusion authority under South Carolina’s interpretation.
And there’s the rub. If credited, South Carolina’s submission that the term
“qualified” means whatever the state says would strip the free-choice-of-provider provision
of all meaning and shortchange the federal side of the bargain. South Carolina argues the
provision would still have some meaning by ensuring that recipients could see any provider
that meets the state’s qualifications. But we do not believe that Congress could have
intended to confer a right so empty in terms so strong. “If the states are free to set any
qualifications they want—no matter how unrelated to the provider’s fitness to treat
Medicaid patients—then the free-choice-of-provider requirement could be easily
undermined by simply labeling any exclusionary rule as a ‘qualification.’” Planned
Parenthood of Ind., 699 F.3d at 978.
South Carolina nonetheless contends that the Medicaid Act’s silence as to the
meaning of “qualified” is grounds for interpreting it to allow states expansive exclusionary
powers. See Appellant’s Reply Brief at 10 (“Congress leaving the term ‘qualified’
undefined purposely creates a vague or amorphous provision with the idea being that doing
so allows the states to tailor their State Plan.”). That, however, is not how we ordinarily
interpret undefined statutory terms, let alone a term pegged to a phrase as clear as “to
perform the [medical] service or services required.” 42 U.S.C. § 1396a(a)(23)(A).
The state next seeks refuge in the canon against surplusage. If “qualified” means
professionally competent, South Carolina argues, then its inclusion in the free-choice-of-
provider provision is “pointless and redundant” because state licensing schemes already
exclude incompetent providers from the Medicaid pool. See Appellant’s Reply Brief at 13.
But this view ignores the language of the free-choice-of-provider provision. We do not
lightly impute to Congress an intent to use terms that “have no operation at all.” Marbury
v. Madison, 5 U.S. (1 Cranch) 137, 174 (1803). And as noted above, South Carolina’s
reading works precisely this result by allowing states—at their discretion—to nullify the
free-choice-of-provider provision entirely. Granted, South Carolina agrees that a state’s
policies cannot eliminate “all recipient choice,” which the state interprets to require only
that at least two “qualified” providers remain available. See Appellant’s Opening Brief at
36-37. But that cannot be right. The free-choice-of-provider provision “does not simply
bar the states from ending all choice of providers, it guarantees to every Medicaid
beneficiary the right to choose any qualified provider.” Planned Parenthood of Ind., 699
F.3d at 979. In order to do that, a state must be restricted in its ability to terminate providers
for reasons unrelated to professional competency.
The case law also does not support South Carolina’s position. On this front, the state
argues that the Court’s decision in O’Bannon v. Town Court Nursing Ctr., 447 U.S. 773
(1980), interpreted the free-choice-of-provider provision to apply only to providers that
“continue to be qualified” in the Medicaid program as a matter of state law. Appellant’s
Opening Brief at 35 (quoting O’Bannon, 447 U.S. at 785). Not so. O’Bannon spoke to the
narrow question whether residents of a nursing home had a right to a pre-termination
hearing before the state could close a home that all parties agreed was professionally
“unqualified” to render patient care. See 447 U.S. at 775-76; see also id. at 776 n.3
(cataloguing the home’s noncompliance with statutes governing, among other topics,
nursing services, physical environment, and medical records). In point of fact, the patients
there did not bring a substantive claim seeking to vindicate their rights under the free-
choice-of-provider provision, but rather sued for violation of their procedural due process
rights. Id. at 775. Along with three of the four circuits to have addressed this issue, we
cannot read O’Bannon to resolve the very different claim raised by plaintiff in the instant
case. See Andersen, 882 F.3d at 1231-32; Gee, 862 F.3d at 460-61; Planned Parenthood of
Ind., 699 F.3d at 977. But see Gillespie, 867 F.3d at 1047 (Shepherd, J., concurring).
Although the free-choice-of-provider provision imposes limits on a state’s
qualification authority, states retain discretionary authority with regards to healthcare
providers. Section 1396a(p)(1) speaks to this balance, providing:
In addition to any other authority, a State may exclude any individual or entity for purposes of participating under the State plan under this subchapter for any reason for which the Secretary [of Health and Human Services] could exclude the individual or entity from participation in a program under subchapter XVIII under section 1320a–7, 1320a–7a, or 1395cc(b)(2) of this title.
This provision confirms that states may and do set standards that relate to providers’
ability to practice in a professionally competent manner. Take the cross-references to start.
They identify various forms of misconduct including patient abuse, failure to furnish
medically necessary services, fraud, license revocation, excessive charges, and failure to
disclose necessary information to state regulators. 42 U.S.C. § 1320a–7. In short, federal
regulations confirm the authority vested in states to “set reasonable standards relating to
the qualifications of providers” on analogous state-law grounds. See 42 C.F.R.
Putting all this together, § 1396a(p)(1) and the free-choice-of-provider provision
operate in pleasant conjunction. The free-choice-of-provider provision confers an
individual right on Medicaid recipients to select the willing and competent provider of their
choice. Section 1396a(p)(1) clarifies that states retain discretionary authority to disqualify
providers as professionally incompetent for nonmedical reasons such as fraud and for any
number of unprofessional behaviors. But the emphasis in § 1396a(p)(1) upon professional
malfeasance in no way deprives states of the latitude they possess, under the free-choice-
of-provider provision itself, to judge a provider’s medical qualifications. Indeed, the
language that begins the free-choice-of-provider provision—“A State plan for medical
assistance must— provide,” 42 U.S.C. § 1396a(a)(23)(A)—presupposes the existence of
discretionary authority in the states as it relates to provider qualifications. Nevertheless,
the fact that the statute’s language and structure suggest the deference due states on the
matter of professional and medical qualifications in no way confers a blank check. Here, it
bears repeating, no one disputes PPSAT’s medical qualifications to perform the family-
planning services required, nor is any professional wrongdoing on the part of PPSAT even
alleged. So it follows that South Carolina cannot arbitrarily disqualify PPSAT upon the
generalized assertion of inapposite state interests without running afoul of the free-choice-
South Carolina attempts to disrupt the congruence between these two provisions by
reading the savings clause “for more than it’s worth.” Planned Parenthood of Ind., 699
F.3d at 979. The state argues that the phrase “[i]n addition to any other authority” in
§ 1396a(p)(1) means it can exclude a provider on any state-law grounds—and for any
reason. See Appellant’s Opening Brief at 32 (“South Carolina’s authority, under Section
1396a(p)(1), to determine whether a provider is qualified does not depend on the state
interest the disqualification seeks to protect.”).
The district court rejected this interpretation, concluding that reading the savings
clause this way would render the right conferred by the free-choice-of-provider provision
meaningless. Baker, 326 F. Supp. 3d at 47-48. We agree. If Congress had in fact harbored
the sweeping intent that South Carolina gleans from § 1396a(p)(1), there would be no
reason to bother with the free-choice-of-provider provision, as any state-law ground could
serve as the basis to eliminate a patient’s choice. To say that this would warp the law
enacted by Congress is an understatement.
Moreover, South Carolina’s interpretation also finds no support in the four corners
of § 1396a(p)(1). For one thing, the phrase “[i]n addition to any other authority” serves a
specific purpose. It lists what “is a non-exclusive list of specific grounds upon which states
may bar providers from participating in Medicaid.” Planned Parenthood of Ind., 699 F.3d
at 979. The grounds identified—spanning everything from financial fraud to medical
malpractice—relate generally to professional malfeasance. In contrast, the type of
“qualification” the state argues for under § 1396a(p)(1) is different in kind. South
Carolina’s exclusion of PPSAT from its Medicaid network has nothing to do with
professional misconduct or for that matter with PPSAT’s ability to safely and
professionally perform plaintiff’s required family-planning services. PPSAT, after all,
continues to deliver these services to thousands of South Carolinians each year—to which
the state has no objection. See J.A. 91.
What we are left with, ironically, is the state’s attempt to eliminate almost the
entirety of § 1396a(p)(1). For if the phrase “[i]n addition to any other authority” authorizes
any and all state interests to serve as a basis for termination, there would be no need to list
the specific grounds identified in § 1396a(p)(1). Congress sometimes employs the broad
version of the phrase. See, e.g., 7 U.S.C. § 2279(c)(4)(B) (“The authority to carry out this
section shall be in addition to any other authority provided in this or any other Act.”)
(emphasis added). But it did not do so here, and the foregoing discussion makes clear that
this was not through inadvertence.
Consider also the cases cited by the state to support its broad reading of the savings
clause. In Guzman v. Shewry, 552 F.3d 941 (9th Cir. 2009), the Ninth Circuit did not hold
that § 1396a(p)(1) grants states plenary exclusion authority over healthcare providers.
Rather, that court expressly recognized that states may exclude providers “for reasons
bearing on the individual’s or entity’s professional competence, professional performance,
or financial integrity.” Id. at 949 (citing 42 U.S.C. § 1320a-7(b)(5)). In any event, the
provider in Guzman was deemed “unqualified” based on a state law guarding against
professional malfeasance—as were the providers in all cases interpreting § 1396a(p)(1)
that South Carolina cites. See id. at 946-47 (fraud or abuse); First Med. Health Plan v.
Vega-Ramos, 479 F.3d 46 , 49-50 (1st Cir. 2007) (financial self-dealing); Triant v. Perales,
491 N.Y.S.2d 486 , 488 (App. Div. 1985) (shoddy record-keeping).
In the end, to read § 1396a(p)(1) as imposing such severe limits on the scope of the
right conferred by the free-choice-of-provider provision would eviscerate the Medicaid
Act’s cooperative scheme and turn the congressional judgment on its head. Congress,
aware of the deep national divide on a topic so sensitive as abortion, sought to strike a
balance in the Medicaid Act. Starting in 1976, Congress has prohibited federal funds from
being used to finance abortions, excepting instances of rape, incest, or to save the life of
the mother. Harris v. McRae, 448 U.S. 297 , 302 (1980) (describing the Hyde Amendment).
On the other hand, Congress provided extra protections for beneficiaries’ freedom of
choice among family-planning providers, something it accomplished while amending the
free-choice-of-provider provision to accommodate Medicaid managed care plans. 5 The
Secretary, to wit, may waive the free-choice-of-provider provision when a state implements
a Medicaid managed care plan. But with an important caveat: An individual’s right to seek
out non-abortion services from a qualified family-planning provider of her choice cannot
be waived. 42 U.S.C. §§ 1396a(a)(23)(B), 1396d(a)(4)(C); see also Betlach, 727 F.3d at
972 (“Even if a state otherwise exercises its option to implement a managed-care system,
§ 1396a(a)(23)(B) makes clear that as to family planning services, state Medicaid plans
must afford recipients the full range of free choice of provider.”). This implicit bargain
agreed to by the political branches is one that we are bound to respect.
Because the individual plaintiff has a private right of action to challenge South
Carolina’s denial of her right to the qualified and willing family-planning provider of her
choice, we agree with the district court that she has demonstrated a substantial likelihood
of success on her free-choice-of-provider claim. We also hold that the district court did not
5 Medicaid managed care plans allow a state to contract with a limited selection of healthcare providers. Through this arrangement, states can lower their Medicaid expenses and streamline their delivery of health care. There is no contention that any waiver of the free-choice-of-provider provision took place here.
abuse its discretion in enjoining South Carolina from terminating PPSAT’s provider
It is clear that the plaintiff would suffer irreparable harm in the absence of a
preliminary injunction. Denial of her statutory right to select a qualified provider visits a
tangible harm: diminished access to high-quality health care suited to the individual
plaintiff’s needs. See Appellees’ Brief at 39. That PPSAT may be one of many providers
available to the individual plaintiff through South Carolina’s Medicaid network is not
dispositive; the free-choice-of-provider provision, as we have noted, guarantees a patient’s
access to her preferred provider, save on matters of professional integrity and competency.
South Carolina has a legitimate interest in ensuring that state dollars do not subsidize
abortion. But we are not prepared to disrupt the district court’s finding that the state’s
reimbursement of PPSAT on a fee-for-service basis guards against the indirect
subsidization of abortion. Finally, an injunction would serve the public interest by
preserving the individual plaintiff’s statutory right under the free-choice-of-provider
provision and ensuring “affordable access to competent health care by some of South
Carolina’s neediest citizens,” Baker, 326 F. Supp. 3d at 50, whose health challenges are
every bit as real as those of citizens of greater means.
We do not doubt that South Carolina’s termination of PPSAT’s provider agreement
was intended “to further [its] own legitimate interests in protecting prenatal life.” Planned
Parenthood of Se. Pa. v. Casey, 505 U.S. 833 , 853 (1992). Reasonable people can disagree
with how Congress chose to balance state flexibility on the one hand, and enforcement of
federal entitlements on the other. But in all events federal courts are ill-suited to second-
guess this act of political judgment in the Medicaid Act. An injury so concrete and a right
so clear is something that the courts must respect, else we forsake natural and
straightforward readings of statutory text in favor of spinning ever-finer webs of
circumvention that lead to our desired outcomes. To subscribe to this portentous course is
to abandon the very source of our authority and the mandate that alone makes the Third
Branch a distinctive organ of our government. The judgment of the district court is
RICHARDSON, Circuit Judge, concurring:
I join in affirming the grant of the preliminary injunction. The Majority correctly
recognizes that applying existing Supreme Court precedents requires that we find
§ 1396a(a)(23) to unambiguously create a right privately enforceable under § 1983 to
challenge a State’s determination of whether a Medicaid provider is “qualified.” Six
Circuits now recognize that § 1396a(a)(23) creates this enforceable right. 1 One Circuit
does not. 2
As lower court judges, we are bound to do our level best to apply the law as it is,
not how it may become. We have done so here. But when binding precedents present us
with a bit of “a mess of the issue,” Gee v. Planned Parenthood of Gulf Coast, Inc., 139 S.
Ct. 408, 409 (2018) (Thomas, J., dissenting from denial of certiorari), our job becomes
1 See Planned Parenthood S. Atlantic & Julie Edwards v. Baker, No. 18-2133 (4th Cir. 2019); Planned Parenthood of Kan. & Mid-Mo. v. Andersen, 882 F.3d 1205 (10th Cir. 2018), cert. denied, 139 S. Ct. 638 (2018); Planned Parenthood of Gulf Coast, Inc. v. Gee, 862 F.3d 445 (5th Cir. 2017), cert. denied, 139 S. Ct. 408 (2018); Planned Parenthood Ariz. Inc. v. Betlach, 727 F.3d 960 (9th Cir. 2013), cert. denied, 571 U.S. 1198 (2014); Planned Parenthood of Ind., Inc. v. Comm’r of Ind. State Dep’t of Health, 699 F.3d 962 (7th Cir. 2012), cert. denied, 569 U.S. 1004 (2013); Harris v. Olszewski, 442 F.3d 456 (6th Cir. 2006). 2 See Does v. Gillespie, 867 F.3d 1034 (8th Cir. 2017). And in the last two years, other judges have raised questions about recognizing the right of action. See Planned Parenthood of Greater Tex. Family Planning and Preventive Health Servs., Inc. v. Smith, 913 F.3d 551 , 569–73 (5th Cir. 2019) (Jones, J., concurring); Gee, 862 F.3d at 473–86 (Owen, J., dissenting); Andersen, 882 F.3d at 1238–49 (Bacharach, J., concurring in part and dissenting in part).
The challenge here derives from a broader question lurking in the background.
What is the proper framework for determining whether a given statute creates a right that
is privately enforceable under § 1983? And specifically, has Wilder v. Virginia Hospital
Ass’n, 496 U.S. 498 (1990), a case relied on in other Circuits’ decisions and in our own,
been repudiated (or even effectively overruled)? There are indications that it has. See
Armstrong v. Exceptional Child Ctr., Inc., 135 S. Ct. 1378 , 1386 n.* (2015). But we do
not lightly conclude that the Supreme Court has overruled its prior cases—that job is for
the Supreme Court alone. See Hohn v. United States, 524 U.S. 236 , 252–53 (1998) (“Our
decisions remain binding precedent until we see fit to reconsider them, regardless of
whether subsequent cases have raised doubts about their continuing vitality.”).
Like this case, Wilder involved a question of whether a subsection of § 1396a(a) of
the Medicaid Act created a private right of action under § 1983. The particular provision
at issue required a State’s plan for medical assistance to “provide . . . for payment” of
certain medical services “through the use of rates (determined in accordance with methods
and standards developed by the State . . .) which the State finds, and makes assurances
satisfactory to the Secretary, are reasonable and adequate to meet the costs which must be
incurred by efficiently and economically operated facilities. . . .” 496 U.S. at 502–03
(quoting 42 U.S.C. § 1396a(a)(13)(A)) (alterations and emphasis in original). 3
3 In 1997, Congress replaced the provision at issue in Wilder. See Long Term Care Pharmacy All. v. Ferguson, 362 F.3d 50 , 58 (1st Cir. 2004).
The Wilder Court found that service providers had an enforceable right under § 1983
to reimbursement at “reasonable and adequate” rates. 496 U.S. at 512. It reached this
conclusion after looking to three “factors.” First, the Court had “little doubt that health
care providers are the intended beneficiaries” of the provision. Id. at 510. Then the Court
observed that the statutory language imposed a binding obligation on States that participate
in the Medicaid program because the relevant statutory provision was “cast in mandatory
rather than precatory terms,” given its use of the word “must.” Id. Finally, the Court found
that the provision’s obligation was not “too ‘vague and amorphous’ to be judicially
enforceable,” applying what would become the second of the three “factors” to find clarity
in the statutory directive for payment of “rates . . . which the State finds . . . are reasonable
and adequate.” Id. at 503; see id. at 519. 4
Seven years later in Blessing, the Supreme Court instructed courts to apply these
“three principal factors” to determine whether a statutory provision creates an enforceable
right under § 1983. Blessing v. Freestone, 520 U.S. 329 , 338 (1997). The Court applied
4 In finding that this statutory right was “judicially enforceable,” the Court rejected the argument that the language in the Medicaid Act giving States the authority to set rates “which the State finds . . . reasonable and adequate,” granted “a State flexibility to adopt any rates it finds are reasonable and adequate.” Wilder, 496 U.S. at 503, 519 (emphasis added). Though acknowledging that the Act provided States “substantial discretion in choosing among reasonable methods of calculating rates,” the Court held that it was “well within the competence of the Judiciary” to identify which rates were “outside that range that no State could ever find to be reasonable and adequate.” Id. at 519–20. In this way, Wilder seems to foreclose the argument that § 1396a(a)(23) grants South Carolina the flexibility to adopt qualifications based on its interests beyond professional integrity and competency. See Majority Op. at 17, 27–29. And on this record, South Carolina has not explained how its actions fall within its broad discretion to identify professional qualifications. 39
the multifactor test from Wilder to determine whether § 1983 established a private right of
action under Title IV–D of the Social Security Act. See Blessing, 520 U.S. at 338, 340–
When the Supreme Court again revisited privately enforcing a statutory right under
§ 1983 in Gonzaga, it seemed to consider this multifactor test problematic, to say the least.
“[C]onfusion” on how to apply the Blessing factors improperly “led some courts to
interpret Blessing as allowing plaintiffs to enforce a statute under § 1983 so long as the
plaintiff falls within the general zone of interest that the statute is intended to protect.”
Gonzaga Univ. v. Doe, 536 U.S. 273 , 283 (2002); see id. (noting the “uncertainty”).
Gonzaga also questioned “how relations between the branches are served by having courts
apply a multifactor balancing test to pick and choose which federal requirements may be
enforced by § 1983 and which may not.” Id. at 286 (emphasis added).
The multifactor test is not the only aspect of Wilder that has been questioned. Wilder
had noted that its analysis was “a different inquiry than that involved in determining
whether a private right of action can be implied from a particular statute.” 496 U.S. at 508
n.9. On this point, the Court in Gonzaga would later “reject the notion” that “Wilder
appears to support” that “our implied private right of action cases have no bearing on the
standards for discerning whether a statute creates rights enforceable by § 1983.” 536 U.S.
at 283. To the contrary, “our implied right of action cases should guide the determination
of whether a statute confers rights enforceable under § 1983.” Id.
So are Wilder, specifically, and the Blessing factors, generally, still good law? On
the one hand, we look to the three factors from Blessing. 520 U.S. at 338, 340–41. But on
the other hand, we must find a bright-line: nothing “short of an unambiguously conferred
right.” Gonzaga, 536 U.S. at 283.
But Gonzaga did not explicitly overrule Blessing’s three-factor approach. Nor did
it plainly discard Wilder’s application of the factors. See Gonzaga, 536 U.S. at 289–90
(distinguishing Wilder on its facts). More recently, the Court has more directly questioned
Wilder’s reasoning and validity. Armstrong, 135 S. Ct. at 1386 n.* (“Respondents do not
claim that Wilder establishes precedent for a private cause of action in this case. They do
not assert a § 1983 action, since our later opinions plainly repudiate the ready implication
of a § 1983 action that Wilder exemplified.” (emphasis added)). Yet, at least in our Circuit,
Wilder and Blessing remain controlling. See, e.g., Doe v. Kidd, 501 F.3d 348 , 356 (4th Cir.
2007) (relying on Wilder and Blessing to find § 1396a(a)(8) confers an individual right).
Despite the “confusion” and “uncertainty,” we must apply the law as we find it.
Today, our opinion is “guide[d]” by the three factors from Blessing. Majority Op. at 14.
Following their guide requires that we find a private right of action under § 1983 to
challenge a State’s determination of whether a Medicaid provider is “qualified” under 42
U.S.C. § 1396a(a)(23). And so I do. But I do so with hope that clarity will be provided.